Doctors slow to join program to treat addicts

Megan Detweiler R.N., head nurse at the Howard Center's Chittenden Clinic in South Burlington on Thursday, with an 8 milligram Suboxone strip, which is used to treat opiate addicts.
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Vermont's medical community remains reluctant to join the effort to combat heroin and opioid addiction, despite a call for action from Gov. Peter Shumlin and a spike in the number of people seeking treatment at five regional hubs around the state.

According to data provided by the Health Department and Department of Vermont Health Access, 2,506 Vermonters were being treated at the hubs as of mid-September, up 57 percent since Shumlin declared heroin and opiate addiction a crisis for Vermont in his January State of the State address.

Meanwhile, the number of doctors signed up to provide ongoing care to patients battling addiction as the "spokes" part of the state's hub-and-spoke treatment network is at 138, the same number it was at the beginning of the year. A few of the "spokes" doctors work in the hubs; the rest are hometown primary care physicians.

The hubs are designed to assess patients seeking treatment for their addiction; the spokes are supposed to assume ongoing care of the patients once their treatment process is established.

"The absence of enough spokes is problematic," said Bob Bick, who oversees the operation the Burlington treatment hub as HowardCenter's director substance abuse services.

Bick said a shortage of "spokes" doctors means patients ready to be shifted from hubs to follow-up treatment with a primary care physician have to stay with the hub longer, forcing other people in need of treatment to remain on hub waiting lists.

"In our clinic, there's probably 175 to 200 patients who are set to be accommodated by a 'spoke' physician," Bick said. The Burlington hub in mid-September had 899 patients and a waiting list of about 250, he said.

According to state health officials, the hometown ongoing care doctors are treating 2,005 patients with addiction issues, or about 14 patients per participating doctor.

Madeleine Mongan, an executive with the Vermont Medical Society, said her organization has tried to encourage more doctors to join the hub-and-spokes system, without much success.

Mongan said some doctors are leery of taking on patients with addiction issues until they are assured sufficient drug counseling and nurse support is available to assist them.

"The 'spokes' supports are still gearing up," Mongan said. "They're not statewide yet ... (but) the availability of support is improving."

Bick said doctors are willing to provide addiction treatment care when the patient is someone they already know. The reluctance comes when they are unfamiliar with the patient and what problems taking on that person might pose, ranging from drug relapses to psychological troubles.

"Trying to find a physician willing to take on someone with whom they have no previous relationship is hard," Bick said. "It's a challenging clinical population."

Program growth

The struggle to get more primary doctors to treat patients with addiction issues comes as spending on the treatment of Vermonters for heroin and opiate addiction is soaring.

Vermont has budgeted $13.2 million for opioid treatment in fiscal 2015 year, which began July 1. That's $8 million more than the state spent on opioid treatment in fiscal 2014, and underlines Shumlin's decision to make confronting heroin and opiate abuse a top priority of his administration.

"The governor was very vocal in focusing on the issue," said Barbara Cimaglio, deputy commissioner for alcohol and drug abuse programs for the Health Department. "There was a greater recognition that we had a serious, intractable problem and that it would take all of us working on it."

That recognition has led to the opening of two new treatment hubs in the last year, in Rutland and the Northeast Kingdom, and a stepped up effort to provide treatment for addicts statewide.

Wayne Warnken, a longtime ongoing addiction treatment doctor who works out of the Community Health Center in Burlington, said the evolution of the hub-and-spokes program has made his work with recovering addicts easier to handle.

"The trend is they're trying to get people stabilized as opposed to being early in recovery and walking into my office," Warnken said. "I used to get a lot of visits like that, people saying 'Are you going to help me today?'"

Warnke, who has 30 patients under treatment with Suboxone, said he's licensed to take on up to 100 patients but won't do it. "I'm maxed out," he said.

He is, however, glad to be a "spokes" doctor.

"We need to treat addiction as just another chronic disease," he said. "It's a very satisfying part of my practice."

It's unclear, what will happen to the hub-and-spokes program if state funding can't keep up with the demand for services or faces cuts because of other looming budgetary pressures.

Most of the $13.2 million that now goes to cover the costs of medication-assisted treatment, particularly Suboxone, is paid for through Medicaid under a temporary arrangement where the federal government is picking up 90 percent of the tab.

By then end of next year, that arrangement will end and the federal government will pay for only 45 percent of the cost, with the state paying the rest.

Suboxone cost

Suboxone, a derivative of buprenorphine, is the only addiction medication that qualified ongoing treatment doctors can administer. Thus, all 2,005 of the patients being treated by these doctors are on Suboxone.

By comparison, two-thirds of the 2,506 patients being treated in the regional hubs are being prescribed methadone, an older but more potent medication. Because of federal rules, methadone can only be administered in a hub setting.

The difference in price between the two medications is staggering. According to state figures, a four-week regimen of Suboxone costs $406, while four weeks of methadone costs only $10.50.

Those drug costs, once in place, are unlikely to decline because most recovering addicts remain on the medication for months or years.

"One question I think the system has to ask is: At what point do you incorporate into the decision-making process a concern about whether it can continue to afford prescribing buprenorphine?" Bick said of the more expensive drug.

If more doctors ultimately agree to become "spokes" in the state's opioid treatment program, that could drive up the cost of combating heroin and opiate abuse.

"The demand for addiction treatment services continues to be there," Bick said. "The state ... is likely to face a significant challenge in fiscal 2016," Bick said.

Suboxone has also come under criticism as a drug that is itself being abused, both on the street and inside Vermont's eight prisons.

"The abuse and misuse of it is really dangerously being overlooked," said Stowe psychologist Rick Barnett, president of the Vermont Psychological Association. "It's the drug of choice in prison."

In response to concerns about Suboxone abuse, the Legislature this spring passed a law requiring doctors prescribing the medication to consult the Vermont Prescription Monitoring System before giving the drug to a patient.

The law, Act 195, also requires doctors to have patients seeking addiction treatment be screened beforehand to see if they need counseling in addition to other services.

Barnett said Suboxone, like any pharmaceutical product, works well for some people but not for others. Using one drug to fix a problem created by another drug is sometimes a too simplistic solution.

"Everybody wants a quick fix," Barnett said. "There are a lot of patients who, after a few months on Suboxone, really don't want to use it anymore. They still feel imprisoned by addiction."

Contact Sam Hemingway at 660-1850 or shemingway@freepressmedia.com. Follow Sam on Twitter at www.twitter.com/SamuelHemingway.